146. Adult and Pediatric Lung and HeartLung Goal Exception Form_Instructions

OMB No. 0915-0157; Expiration Date: XX/XX/20XX

Adult and Pediatric Lung and HeartLung Goal Exception Form

Patient Information

The following fields, from the candidate's Waitlist record, are read-only. If the information is incorrect, it may be updated on the candidate's Waitlist record.

Transplant Center: Verify the transplant center code is correct.

Name: Verify the candidate's name is correct.

Date of birth: Verify the candidate's date of birth is correct.

Waitlist ID: Verify the candidate's Waitlist ID number is correct.

SSN: Verify the candidate's social security number is correct.

Blood type: Verify the candidate's blood type is correct.

Request New Exception

Request new exception: Select the appropriate goal type from the drop down.

Medical urgency

Post-transplant outcomes

Biological disadvantages

Patient access

Justification narrative: Enter a detailed justification clinical narrative of the candidate’s condition.

Authorization

Transplant physician name: Enter the transplant physician's name. This is a required field.

Transplant physician NPI: Enter the transplant physician's NPI number. The NPI must be 10 digits. This is a required field.

Email decision to: Enter at least one and up to three email addresses to receive notification of the outcome of the vote. Including up to three email addresses may be important to account for time off or out-of-office. This is a required field.

Public Burden Statement: The private, non-profit Organ Procurement and Transplantation Network (OPTN) collects this information in order to perform the following OPTN functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monitor compliance of member organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0157 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data collected will be subject to Privacy Act protection (Privacy Act System of Records #09-15-0055). Data collected by the private non-profit OPTN also are well protected by a number of the Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as prescribed by OMB Circular A-130, Appendix III, Security of Federal Automated Information Systems, and the Departments Automated Information Systems Security Program Handbook. The public reporting burden for this collection of information is estimated to average 0.27 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov.   

OPTN Restricted

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Adult and Pediatric Lung and HeartLung Goal Exception Form Instructions
File Created	2025:09:28 12:48:16Z